ISSN 1007-9327 (print) ISSN 2219-2840 (online) World ... · 3145 Integrated genomic analysis for prediction of survival for patients with liver cancer using The Cancer Genome Atlas

World Journal of GastroenterologyWorld J Gastroenterol 2018 July 28; 24(28): 3055-3200

ISSN 1007-9327 (print)ISSN 2219-2840 (online)

Published by Baishideng Publishing Group Inc

S

REVIEW3055 Non-pharmacologicaltherapiesforinflammatoryboweldisease:Recommendationsforself-careand

physicianguidance

Duff W, Haskey N, Potter G, Alcorn J, Hunter P, Fowler S

3071 Helicobacterpylori inhumanhealthanddisease:MechanismsforlocalgastricandsystemiceffectsBravo D, Hoare A, Soto C, Valenzuela MA, Quest AF

3090 Protontherapyforhepatocellularcarcinoma:Currentknowledgeandfutureperspectives

Yoo GS, Yu JI, Park HC

MINIREVIEWS3101 Encapsulatingperitonealsclerosis

Danford CJ, Lin SC, Smith MP, Wolf JL

3112 Considerationsforbariatricsurgeryinpatientswithcirrhosis

Goh GB, Schauer PR, McCullough AJ

ORIGINAL ARTICLEBasic Study

3120 ImpactofhyperglycemiaonautoimmunepancreatitisandregulatoryT-cells

Müller-Graff FT, Fitzner B, Jaster R, Vollmar B, Zechner D

3130 Moxibustiontreatmentmodulatesthegutmicrobiotaandimmunefunctioninadextransulphatesodium-

inducedcolitisratmodel

Qi Q, Liu YN, Jin XM, Zhang LS, Wang C, Bao CH, Liu HR, Wu HG, Wang XM

3145 IntegratedgenomicanalysisforpredictionofsurvivalforpatientswithlivercancerusingTheCancer

GenomeAtlas

Song YZ, Li X, Li W, Wang Z, Li K, Xie FL, Zhang F

Retrospective Study

3155 Multikinaseinhibitor-associatedhand-footskinreactionasapredictorofoutcomesinpatientswith

hepatocellularcarcinomatreatedwithsorafenib

Ochi M, Kamoshida T, Ohkawara A, Ohkawara H, Kakinoki N, Hirai S, Yanaka A

Observational Study

3163 HealthbehaviorsofKoreanadultswithhepatitisB:Findingsofthe2016KoreanNationalHealthand

NutritionExaminationSurvey

Yi YH, Kim YJ, Lee SY, Cho BM, Cho YH, Lee JG

Contents Weekly Volume 24 Number 28 July 28, 2018

� July 28, 2018|Volume 24|�ssue 28|WJG|www.wjgnet.com

S

SYSTEMATIC REVIEWS3171 Roleofcolectomyinpreventingrecurrentprimarysclerosingcholangitisinlivertransplantrecipients

Buchholz BM, Lykoudis PM, Ravikumar R, Pollok JM, Fusai GK

META-ANALYSIS3181 HepatitisBreactivationinpatientsreceivingdirect-actingantiviraltherapyorinterferon-basedtherapyfor

hepatitisC:Asystematicreviewandmeta-analysis

Jiang XW, Ye JZ, Li YT, Li LJ

CASE REPORT3192 Regulatingmigrationofesophagealstents-managementusingaSengstaken-Blakemoretube:Acase

reportandreviewofliterature

Sato H, Ishida K, Sasaki S, Kojika M, Endo S, Inoue Y, Sasaki A

LETTERS TO THE EDITOR3198 Geneticanalysisishelpfulforthediagnosisofsmallbowelulceration

Umeno J, Matsumoto T, Hirano A, Fuyuno Y, Esaki M

Contents Weekly Volume 24 Number 28 July 28, 2018

�� July 28, 2018|Volume 24|�ssue 28|WJG|www.wjgnet.com

NAMEOFJOURNALWorld Journal of Gastroenterology

ISSNISSN 1007-9327 (print)ISSN 2219-2840 (online)

LAUNCHDATEOctober 1, 1995

FREQUENCYWeekly

EDITORS-IN-CHIEFDamian Garcia-Olmo, MD, PhD, Doctor, Profes-sor, Surgeon, Department of Surgery, Universidad Autonoma de Madrid; Department of General Sur-gery, Fundacion Jimenez Diaz University Hospital, Madrid 28040, Spain

Stephen C Strom, PhD, Professor, Department of Laboratory Medicine, Division of Pathology, Karo-linska Institutet, Stockholm 141-86, Sweden

Andrzej S Tarnawski, MD, PhD, DSc (Med), Professor of Medicine, Chief Gastroenterology, VA Long Beach Health Care System, University of Cali-fornia, Irvine, CA, 5901 E. Seventh Str., Long Beach,

CA 90822, United States

EDITORIALBOARDMEMBERSAll editorial board members resources online at http://www.wjgnet.com/1007-9327/editorialboard.htm

EDITORIALOFFICEZe-Mao Gong, DirectorWorld Journal of GastroenterologyBaishideng Publishing Group Inc7901 Stoneridge Drive, Suite 501, Pleasanton, CA 94588, USATelephone: +1-925-2238242Fax: +1-925-2238243E-mail: [email protected] Desk: http://www.f6publishing.com/helpdeskhttp://www.wjgnet.com

PUBLISHERBaishideng Publishing Group Inc7901 Stoneridge Drive, Suite 501, Pleasanton, CA 94588, USATelephone: +1-925-2238242Fax: +1-925-2238243E-mail: [email protected] Desk: http://www.f6publishing.com/helpdeskhttp://www.wjgnet.com

Contents

EDITORS FOR THIS ISSUE

Responsible Assistant Editor: Xiang Li Responsible Science Editor: Xue-Jiao WangResponsible Electronic Editor: Shu-Yu Yin Proofing Editorial Office Director: Ze-Mao GongProofing Editor-in-Chief: Lian-Sheng Ma

PUBLICATIONDATEJuly 28, 2018

COPYRIGHT© 2018 Baishideng Publishing Group Inc. Articles pub-lished by this Open-Access journal are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.

SPECIALSTATEMENTAll articles published in journals owned by the Baishideng Publishing Group (BPG) represent the views and opin-ions of their authors, and not the views, opinions or policies of the BPG, except where otherwise explicitly indicated.

INSTRUCTIONSTOAUTHORSFull instructions are available online at http://www.wjgnet.com/bpg/gerinfo/204

ONLINESUBMISSIONhttp://www.f6publishing.com

World Journal of GastroenterologyVolume 24 Number 28 July 28, 2018

EditorialboardmemberofWorldJournalofGastroenterology,NobuhiroOhkohchi,MD,PhD,Professor,DepartmentofSurgery,DivisionofGastroenterologyandHepatobiliarySurgeryandOrganTransplantation,UniversityofTsukuba,Tsukuba305-8575,Japan

World Journal of Gastroenterology (World J Gastroenterol, WJG, print ISSN 1007-9327, online ISSN 2219-2840, DOI: 10.3748) is a peer-reviewed open access journal. WJG was estab-lished on October 1, 1995. It is published weekly on the 7th, 14th, 21st, and 28th each month. The WJG Editorial Board consists of 642 experts in gastroenterology and hepatology from 59 countries. The primary task of WJG is to rapidly publish high-quality original articles, reviews, and commentaries in the fields of gastroenterology, hepatology, gastrointestinal endos-copy, gastrointestinal surgery, hepatobiliary surgery, gastrointestinal oncology, gastroin-testinal radiation oncology, gastrointestinal imaging, gastrointestinal interventional ther-apy, gastrointestinal infectious diseases, gastrointestinal pharmacology, gastrointestinal pathophysiology, gastrointestinal pathology, evidence-based medicine in gastroenterol-ogy, pancreatology, gastrointestinal laboratory medicine, gastrointestinal molecular biol-ogy, gastrointestinal immunology, gastrointestinal microbiology, gastrointestinal genetics, gastrointestinal translational medicine, gastrointestinal diagnostics, and gastrointestinal therapeutics. WJG is dedicated to become an influential and prestigious journal in gas-troenterology and hepatology, to promote the development of above disciplines, and to improve the diagnostic and therapeutic skill and expertise of clinicians.

World Journal of Gastroenterology (WJG) is now indexed in Current Contents®/Clinical Medicine, Science Citation Index Expanded (also known as SciSearch®), Journal Citation Reports®, Index Medicus, MEDLINE, PubMed, PubMed Central and Directory of Open Access Journals. The 2018 edition of Journal Citation Reports® cites the 2017 impact factor for WJG as 3.300 (5-year impact factor: 3.387), ranking WJG as 35th among 80 journals in gastroenterology and hepatol-ogy (quartile in category Q2).

ABOUT COVER

INDEXING/ABSTRACTING

AIMS AND SCOPE

�� July 28, 2018|Volume 24|�ssue 28|WJG|www.wjgnet.com

Franz-Tassilo Müller-Graff, Brigitte Vollmar, Dietmar Zechner,

Institute for Experimental Surgery, Rostock University Medical Center, Rostock 18057, Germany

Brit Fitzner, Robert Jaster, Division of Gastroenterology, Department of Medicine Ⅱ, Rostock University Medical Center, Rostock 18057, Germany

O R C I D n u m b e r : F r a n z - Ta s s i l o M ü l l e r - G r a f f (0000-0002-0566-9278); Brit Fitzner (0000-0003-3077-1351); Robert Jaster (0000-0002-8220-4570); Brigitte Vollmar (0000-0002-2403-9597); Dietmar Zechner (0000-0002-2075-7540).

Author contributions: FTMG and BF performed experiments; RJ evaluated histological sections; DZ designed and performed experiments; FTMG and DZ wrote the manuscript; all authors interpreted the results and revised the manuscript.

Supported by the Deutsche Forschungsgemeinschaft (DFG research group FOR 2591), No. 321137804, No. ZE 712/1-1 and No. VO 450/15-1.

Institutional animal care and use committee statement: All experiments were executed in accordance with the German legislation, the EU-directive 2010/63/EU and approved by the Landesamt für Landwirtschaft, Lebensmittelsicherheit und Fischerei Mecklenburg-Vorpommern (7221.3-1.1-004/13).

Conflict-of-interest statement: To the best of our knowledge, no conflict of interest exists.

Data sharing statement: Data are available from the corresponding author at [email protected].

ARRIVE guidelines statement: The Manuscript was prepared and revised according to the ARRIVE guidelines.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on

different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicited manuscript

Correspondence to: Dietmar Zechner, PhD, Academic Research, Senior Scientist, Institute for Experimental Surgery, Rostock University Medical Center, Schillingallee 69a, Rostock 18057, Germany. [email protected]: +49-381-4942512Fax: +49-381-4942502

Received: April 17, 2018Peer-review started: April 17, 2018First decision: June 11, 2018Revised: June 17, 2018Accepted: June 27, 2018 Article in press: June 27, 2018 Published online: July 28, 2018

AbstractAIMTo evaluate the influence of hyperglycemia on the pro-gression of autoimmune pancreatitis.

METHODSWe induced hyperglycemia by repetitive intraperitoneal (ip) injection of 50 mg/kg streptozotocin in MRL/MpJ mice, which develop autoimmune pancreatitis due to a genetic predisposition. We compared the extent of inflammation (histological score, CD3+ lymphocytes, CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells) in the pancreas of hyperglycemic and normoglycemic mice. We also analyzed the number of leukocytes, lymphocytes, granulocytes and monocytes in the blood. In addition, we determined the percentage of CD3+ lymphocytes, CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells, Foxp3+ CD25+ T-helper and Foxp3- T-helper cells in the spleen by flow cytometry.

3120 July 28, 2018|Volume 24|Issue 28|WJG|www.wjgnet.com

ORIGINAL ARTICLE

Impact of hyperglycemia on autoimmune pancreatitis and regulatory T-cells

Basic Study

Franz-Tassilo Müller-Graff, Brit Fitzner, Robert Jaster, Brigitte Vollmar, Dietmar Zechner

Submit a Manuscript: http://www.f6publishing.com

DOI: 10.3748/wjg.v24.i28.3120

World J Gastroenterol 2018 July 28; 24(28): 3120-3129

ISSN 1007-9327 (print) ISSN 2219-2840 (online)

RESULTSTreatment with streptozotocin caused a strong induction of hyperglycemia and a reduction in body weight (P < 0.001). Severe hyperglycemia did not, however, lead to an aggravation, but rather to a slight attenuation of autoimmune pancreatitis. In the pancreas, both the his-tological score of the pancreas as well as the number of CD3+ lymphocytes (P < 0.053) were decreased by hyperglycemia. No major changes in the percentage of CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells were ob-served between hyperglycemic and normoglycemic mice. Hyperglycemia increased the numbers of leukocytes (P < 0.001), lymphocytes (P = 0.016), granulocytes and monocytes (P = 0.001) in the blood. Hyperglycemia also moderately reduced the percentage of CD3+ lymphocytes (P = 0.057), significantly increased the percentage of Foxp3+ T-helper cells (P = 0.018) and Foxp3+ CD25+ T-helper cells (P = 0.021) and reduced the percentage of Foxp3- T-helper cells (P = 0.034) in the spleen.

CONCLUSIONHyperglycemia does not aggravate but moderately atte-nuates autoimmune pancreatitis, possibly by increasing the percentage of regulatory T-cells in the spleen.

Key words: Autoimmune disease; Diabetes; Treg; FoxP3; Autoimmune pancreatitis; MRL/MpJ mice

© The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.

Core tip: Temporary or sustained hyperglycemia can be observed in about 42%-66% of patients with auto-immune pancreatitis. However, it is unknown to what extent hyperglycemia has an influence on the course of this disease. This preclinical study demonstrates that hyperglycemia does not lead to an aggravation but rather an attenuation of autoimmune pancreatitis. Thus, this result might have the clinical implication that a tight adjust-ment of blood glucose concentration in patients with autoimmune pancreatitis is not needed, because it might not have a beneficial effect on the progression of this disease.

Müller-Graff FT, Fitzner B, Jaster R, Vollmar B, Zechner D. Impact of hyperglycemia on autoimmune pancreatitis and regulatory T-cells. World J Gastroenterol 2018; 24(28): 3120-3129 Available from: URL: http://www.wjgnet.com/1007-9327/full/v24/i28/3120.htm DOI: http://dx.doi.org/10.3748/wjg.v24.i28.3120

INTRODUCTIONAutoimmune pancreatitis (AIP) is a chronic and progressive inflammatory disease of the pancreas with an assumed autoimmune etiology, which was first described by Sarles et al[1] in 1961. The disease is classified by two different histopathological patterns called lympho

plasmacytic sclerosing pancreatitis (LPSP; AIP type 1) and idiopathic duct centric pancreatitis (ICDP; AIP type 2). AIP presents as a versatile disease with cholestasis, obstructive jaundice and pancreatic swelling. Besides the lymphoplasmacytic infiltrate, fibrosis is often pronounced, and a strong response to steroids can be seen. Besides these similarities, the two types differ in other characteristics such as serological markers, in particular elevated levels of IgG4 in LPSP, other organ involvement, or disease relapse[24]. The differentiation to pancreatic neoplasia is difficult, which sometimes can lead to unnecessary pancreatectomy[5].

The inflammatory infiltrate in the pancreas during AIP is mainly composed of lymphocytes and plasma cells as well as some eosinophil and neutrophil granulocytes and dendritic cells. Frequently, Tcells are observed, in particular CD4+Thelper cells and CD8+ cytotoxic cells[6]. In addition, regulatory T cells (Tregs) can be found, which are relevant for the immunological selftolerance by suppressing autoreactive lymphocytes[7]. A specific marker for these cells is the transcription factor forkheadboxprotein P3 (FoxP3), which has a major influence on the development of regulatory Tcells[8,9]. Increased numbers of these cells were found locally in the pancreas as well as in the peripheral blood during AIP[7,10].

A frequent and important complication of AIP is diabetes mellitus (DM). The rate of DM in patients with AIP varies in the literature between 42%66.7%[11,12]. Of those, 34%43% already have DM before AIP, 52%57% show a simultaneous occurrence and 9%14% develop DM after starting a steroid therapy[1315]. These findings suggest that both pathologies are present simultaneously in many patients. A correlation between hyperglycemia and pancreatitis in patients is well recognized, which is in general explained by the fact that pancreatitis can trigger DM[16,17]. Investigations into whether DM or transient hyperglycemia can enhance the development of a pancreatitis in return are rare. Previous preclinical studies demonstrate that diabetes dramatically aggravates the course of ceruleininduced acute and chronic pancreatitis[18,19]. Thus, the purpose of this present study was to address the question of whether diabetes can influence the progression of AIP and to analyze which aspects of this disease are affected by diabetes. We chose to use MRL/MpJ mice, an animal model widely used to study AIP. These mice spontaneously develop AIP with an incidence of 74% in female and 36% in male animals at the age of 3438 wk[20].

MATERIALS AND METHODSAnimalsAll mice were bred in the local SPF facility (the health of the animal stock is routinely checked according to FELASA guidelines) and were exposed to a 12 h artificial light/dark cycle. The mice were caged in groups and were allowed access to water and standard laboratory chow ad libitum. Only female MRL/MpJ mice of the


Müller-Graff FT et al . Hyperglycemia and autoimmune pancreatitis

same age (Sham: 210/204260, STZ: 210/204224 median/interquartile range in days) were either sham or streptozotocintreated (STZ) in the laboratory. Hyperglycemia was induced by intraperitoneal (ip) injection (between 8:00 and 18:00) of 50 mg/kg STZ (SigmaAldrich, Steinheim, Germany) on five consecutive days (day 15). All control mice were shamtreated with 50 mmol/L sodium citrate pH 4.5 instead of STZ. Animals were allocated in a nonrandom manner matching the age of both treatment groups. Tissue was harvested on day 113116 after first STZ injection. For sampling blood and tissue at the indicated time points the animals were anesthetized (by ip injection) with 90 mg/kg ketamine (BelaPharm, Vechta, Germany) and 8 mg/kg xylazine (Bayer Health Care, Leverkusen, Germany). The order in which animals were treated and blood and tissue was sampled was arbitrary. All experiments were executed in accordance with the German legislation, the EUdirective 2010/63/EU and approved by the Landesamt für Landwirtschaft, Lebensmittelsicherheit und Fischerei MecklenburgVorpommern.

Histological and immunofluorescence stainingOn the day of tissue harvesting, the rostral half of the pancreas was placed lengthwise in a biopsy cassette, fixed in 4% phosphatebuffered formalin, and embedded in paraffin. The second half was embedded in TissueTek OCT Compound (Science Services GmbH, Munich, Germany). Paraffin sections of 4 μm thickness were cut and stained with hematoxylin and eosin to evaluate the organ. The histology of the pancreas was investigated by light microscopy (Olympus Corporation, Tokyo, Japan). The severity of autoimmune pancreatitis was determined by scoring the degree of inflammatory cell infiltration and destruction of the parenchyma as described by Kanno et al[20] (0 = no inflammation, healthy organ; 1 = mild inflammation, mononuclear cells present in the interstitium but no destruction of parenchyma; 2 = moderate inflammation, focal destruction of parenchyma with mononuclear cell infiltration; 3 = moderate and diffuse or severe but focal inflammation, diffuse destruction of parenchyma with residues of intact parenchyma; 4 = severe and diffuse inflammation, extended mononuclear cell infiltrates with destruction of acini and replacement by adipose tissue)[20,21]. The score of two to three sections was averaged to receive a final score by at least two independent reviewers in a blinded manner. In case of discrepancies, a third investigator was consulted for a joint review.

Immunofluorescence was performed using the antibodies eFluor660 conjugated rat antiCD3 (500032; dilution: 600x; eBioscience, Frankfurt, Germany), FITC conjugated rat antiCD4 (110041; dilution: 1200 ×; eBioscience), FITC conjugated rat antiCD8 (ab25676; dilution: 200 ×; Abcam, Cambridge, United Kingdom) and rabbit antiFoxP3 (ab54501; dilution: 2100 ×; Abcam) with subsequent secondary antibody Dylight594 goatantirabbit (Dianova, Hamburg, Germany). Immuno

fluorescence was evaluated on scanned sections with a Leica DMI 4000B scanning microscope using a 40 × objective (Leica Microsystems GmbH, Wetzlar, Germany).

Flow cytometryTo evaluate subtypes of Tcells, singlecell suspensions were isolated from the spleen of STZ and shamtreated mice. A total of 1 × 106 leukocytes were stained in a volume of 100 μL PBS pH 7.4 (10010015, Thermo Fisher Scientific GmbH) containing 0.1% BSA (A941810G, SigmaAldrich Chemie GmbH, Taufkirchen, Germany) and appropriate antibodies. These antibodies were eFluor660 conjugated rat anti CD3 (500032; dilution: 100 ×; eBioscience, Frankfurt, Germany), FITC conjugated rat antiCD4 (110041; dilution, 200 ×; eBioscience), PE conjugated rat antiCD8a (BD Cat 553032; dilution: 100 ×; BD Bioscience, Heidelberg, Germany) and PECy7 conjugated rat antiCD25 (250251; dilution: 200 ×; eBioscience). Regulatory Tcells were evaluated by staining with FITC conjugated rat anti CD4 and PE conjugated mouse antiFOXP3 (130093014; dilution, 10 ×; Miltenyi Biotec, Bergisch Gladbach, Germany) according to the manufacturer’s instructions. Data were recorded using a BD FACSCalibur and analyzed using the BD CellQuest Pro software (both Becton Dickinson, NJ, United States).

Analysis of the bloodProgression of hyperglycemia was monitored with the blood glucose meter Contour (Bayer Vital, Leverkusen, Germany). A differential blood cell count was performed with the automated hematology analyzer Sysmex KX 21 (Sysmex Cooperation, Kobe, Japan). To assess acinar cell damage, lipase and amylase activity in blood plasma was analyzed using the Cobas c111 spectrophometer (Roche Diagnostics, Mannheim, Germany).

Statistical analysisData are presented as box plots indicating the median, the 25th and 75th percentiles in the form of a box, and the 10th and 90th percentiles as whiskers. Graphs and statistics were made by using SigmaPlot software version 12.0. Three independent replications (always containing animals of both treatment groups) were done for each experiment. The statistical methods of this study were reviewed by Dr. Änne Glass of the Rostock University Medical Center.

The primary outcome was defined at the beginning of the study as number of TLymphocytes per field in the pancreas. No sample size calculation was used. Mice that did not develop hyperglycemia after treatment with STZ and mice that died during this long term experiment (an identical number of mice in both treatment groups) were excluded from the analysis. For data acquisition and description, the ARRIVE guidelines were respected. The significance of differences was evaluated using a Mann Whitney ranksum test. Differences with P ≤ 0.05 were considered to be significant. Differences with P ≤ 0.08 were considered to indicate a tendency.




Evaluation of local pancreatic inflammation during autoimmune pancreatitis To evaluate the composition of the inflammatory infiltrates in the pancreas, we differentiated between Tlymphocytes (CD3+ cells), Thelper cells (CD3+CD4+cells) and cytotoxic Tcells (CD3+CD8+ cells) by immunofluorescence staining (Figure 3A and B). TLymphocytes (defined as number of CD3+ per field) were decreased in diabetic mice compared to nondiabetic mice (Figure 3C). STZ had almost no influence on the percentage of cytotoxic Tcells (CD8+CD3+ cells × 100 divided by the number of CD3+cells) (Figure 3D), the percentage of Thelper cells (CD4+CD3+ cells × 100 divided by the number of CD3+cells) (Figure 3E) and the percentage of regulatory Tcells (FoxP3+CD4+cells × 100 divided by the number of CD4+ cells) (Figure 3F). Thus, no increase, but rather a reduction in the number of CD3+ leukocytes, was observed in the pancreas of hyperglycemic mice.

Influence of hyperglycemia on leukocytes during autoimmune pancreatitisTo analyze the systemic effect of hyperglycemia during AIP, we sampled blood on the day of tissue harvesting. A significant increase in the number of leukocytes (Figure 4A), lymphocytes (Figure 4B), as well as granulocytes plus monocytes (Figure 4C), was observed in hyperglycemic mice compared to normoglycemic animals.

Since these major differences in the number of immune cells were seen in the blood, we investigated whether hyperglycemia also had an influence on immune cells in the spleen. For this purpose, we analyzed the splenic cells by fluorescent activated cell sorting, which visualized lymphocytes, their stained subpopulations of Thelper cells (CD3+CD4+ cells) and cytotoxic Tcells (CD3+CD8+ cells) as well as regulatory Tcells (FoxP3+CD4+cells) (data not shown and Figure 5A). The quantification of these cells showed a tendentious decrease in the percentage of Tlymphocytes (defined as number of CD3+ cells × 100 divided by the number of lymphocytes) in mice treated with STZ compared to controls (Figure 5B). STZ also modestly increased the percentage of cytotoxic Tcells (CD8+CD3+ cells × 100 divided by the number of CD3+cells) (Figure 5C), and reduced those of Thelper cells (CD4+CD3+ cells × 100 divided by the number of CD3+cells) (Figure 5D). Hyperglycemia significantly increased the percentage of regulatory Tcells (FoxP3+CD4+cells × 100 divided by the number of CD4+ cells) (Figure 5E). Interestingly, hyperglycemia also significantly increased the percentage of CD25 expressing regulatory Tcells (FoxP3+ CD25+ CD4+ cells v 100 divided by the number of CD4+cells) (Figure 5F) compared to normoglycemic mice, whereas the percentage of FoxP3 Tcells (FoxP3CD4+cells × 100 divided by the number of CD4+ cells) was significantly reduced in STZtreated mice (Figure 5G). Thus, a major influence of hyperglycemia on regulatory Tcells was

RESULTSInfluence of hyperglycemia on the course of autoimmune pancreatitis In order to evaluate the influence of hyperglycemia on the course of AIP, we used MRL/MpJ mice due to their spontaneous development of AIP. Distinct cohorts were shamtreated or, in order to induce hyperglycemia, ip injected with STZ for five days and the pancreas was evaluated on day 113116 (Figure 1A). STZ was effective since it increased the blood glucose concentration on day 22 (Sham: 4.6/4.15.5 median/interquartile range in mmol/L. STZ: 22.1/18.225.5 median/interquartile range in mmol/L) until the end of the experiment (Figure 1B) and reduced the body weight (Figure 1C). To investigate the severity of AIP, a histological score with numbers from zero to four was used (Figure 2A). Thirteen weeks of hyperglycemia caused a slight decrease in the severity of the histological score and therefore a moderate, nonsignificant, improvement of AIP when compared to normoglycemic mice (Figure 2B). Little difference was seen in the pancreas to body weight ratio (Figure 2C). Hyperglycemia did not increase the lipase (Figure 2D) or the amylase activity (Figure 2E).

Bloo

d gl

ucos

e (m

mol

/L)

40

30

20

10

0Sham STZ

a

BBo

dy w

eigh

t (g

)55

50

45

40

35

30

25Sham STZ

b

C

Figure 1 Experimental protocol of the hyperglycemic autoimmune pancreatitis model. 28-40 wk old- MRL/MpJ mice were intraperitoneally (ip) injected with streptozotocin on day 1-5 (group: STZ), while one age-matched control cohort was ip injected with the appropriate vehicle (group: Sham). The tissue was harvested on day 113-116; (A) Treatment with STZ increased the blood glucose concentration; (B) and reduced the body weight on day 113-116; (C) Box plots indicate the median, the 25th and 75th percentiles in the form of a box, and the 10th and 90th percentiles as whiskers. The number of animals evaluated was n = 19 (Sham) and n = 17 (STZ). Differences between the indicated cohorts are indicated as significant. aP < 0.001; bP = 0.009. STZ: Streptozotocin-treated.

1xSham

1xSTZ

tissue harvesting

tissue harvesting

Sham

STZ

1 2 3 4 5 113-116dA



observed in the spleen.

DISCUSSIONIn order to test the influence of hyperglycemia on the course of AIP, we compared the progression of AIP in diabetic and nondiabetic mice. Surprisingly, experimental hyperglycemia didn’t cause an aggravation of AIP in MRL/MpJ mice, but moderately improved autoimmune pancreatitis (Figures 2B and 3C). This is in contrast to our previous studies, where hyperglycemia lead to a major aggravation of ceruleininduced acute and chronic pancreatitis[18,19]. This might be explained by the differences in the pathogenesis of these two distinct types of pancreatitis. It is currently controversial whether ceruleininduced pancreatitis is mediated by premature activation of trypsinogen or by persistent activation of the NFκB pathway[22,23]. In contrast, AIP is suggested to be caused by an autoimmunological event, which leads to inflammatory infiltration of the organ[14]. A beneficial effect of hyperglycemia on autoimmune pancreatitis seems to be counterintuitive, since hyperglycemia has been demonstrated to have a deleterious effect on many

organs. However, hyperglycemia can also have an inhibitory effect on the immune system. One could speculate that this impact on the immune system may have a beneficial effect on the progression of some autoimmune diseases.

Our study has several limitations. For example, we cannot completely exclude that instead of high glucose concentration in the blood, the drug we used for inducing hyperglycemia (STZ) influences AIP directly. However, in our opinion it is very unlikely that the alkylating agent STZ, which has been demonstrated to be cytotoxic to cells, directly cures AIP. We also limited our study to evaluate the effect of sustained hyperglycemia on AIP and can therefore not conclude if a transient hyperglycemia also has beneficial effects on the progression of AIP. Another limitation of this study is the use of a histological score, which was defined by the ordinal numbers 0 to 4. Comparing the median of the histological score allows, therefore, only a restricted presentation of complex changes in the histology of the pancreas[20]. We observed that the median of this score was reduced from 2.25 in normoglycemic to 1.50 in hyperglycemic mice (Figure 2B). However, this simple comparison underestimates the


Figure 2 Evaluation of autoimmune pancreatitis. A: Representative images of the histological scores of autoimmune pancreatitis. Arrows point at small inflammatory infiltrates embedded in healthy surrounding tissue; B: hyperglycemia (STZ) reduced the histological score slightly compared to normoglycemic controls (sham); little differences are observed in the pancreas to body weight ratio (C), lipase activity (D), and amylase activity (E). The number of animals evaluated was n = 19 (sham) and n = 17 (STZ) in Panel B and C and n = 19 (Sham) and n = 15 (STZ) in D and E. Scale bar = 50 μm. STZ: Streptozotocin-treated.

Score 1 Score 2

Score 3 Score 4

50 μm

A

Amyl

ase

(U/L

)

8000

6000

4000

2000

0Sham STZ

E

Lipa

se (

U/L

)

100

80

60

40

20

0Sham STZ

D

Panc

reas

to

body

wei

ght

ratio

0.012

0.010

0.008

0.006

0.004

0.002

0.000Sham STZ

C

Sham STZ

His

tolo

gica

l sco

re

4

3

2

1

0

B

50 μm

50 μm 50 μm


observed changes. The same data can also be presented as the percentage of mice with a histological score of ≥ 3. Under normoglycemic conditions, 42% of mice (8 from 19 mice) received a histological score of ≥ 3. Under hyperglycemic conditions, only 6% (1 from 17 mice) received a score of ≥ 3. These high scores were assigned when moderate diffuse or severe focal inflammation plus a diffuse destruction of the acini (score 3) or severe and diffuse inflammation plus extended destruction of acini (score 4) was observed[20,21]. This impressive difference in the percentage of mice with a high histological score suggests that hyperglycemia reduces the damage to the parenchyma, which might indirectly reduce local inflammation. Alternatively, this observation could also

suggest that hyperglycemia reduces inflammation and thus minimizes the damage to the parenchyma. Due to the following observations, we prefer the second option. We found increased numbers of regulatory Tcells and decreased FoxP3 Tcells in the spleen. This is consistent with data in another preclinical study, where it has been described, that decreased numbers of regulatory Tcells and increased numbers of FoxP3 Tcells in the spleen lead to an increased severity of AIP[24]. In both studies, the numbers of regulatory Tcells and FoxP3 Tcells in the spleen correlate with the severity of AIP. Indeed, one study demonstrated a suppressive effect of transferred Tregs on autoimmune pancreatitis in MRL/MpJ mice[25]. However, the observed reduction in the histological score

DAPI CD3+ CD4+50 μm 50 μm 50 μm

A

DAPI CD3+ CD8+ 50 μm50 μm50 μm

B

D

Sham STZ

%CD

8+ T

-lym

phoc

ytes

50

40

30

20

10

0

E

Sham STZ

%CD

4+ T

-lym

phoc

ytes

80

60

40

20

0

F

Sham STZ

%Fo

xP3+

T-h

elpe

r ce

lls

40

30

20

10

0

C

Sham STZ

CD3+

(ce

lls/fi

eld)

140

120

100

80

60

40

20

0

a

Figure 3 Evaluation of the local pancreatic inflammation during autoimmune pancreatitis. Representative images of T-helper cells (CD3+CD4+cells) (A); and cytotoxic T-cells (CD3+CD8+ cells) (B); hyperglycemia induced by STZ decreased the number of T-lymphocytes (defined as number of CD3+ per field) (C); little differences are observed in the percentage of cytotoxic T-lymphocytes (CD8+CD3+ cells × 100 divided by the number of CD3+cells) (D); T-helper cells (CD4+CD3+ cells × 100 divided by the number of CD3+cells) (E); and regulatory T-cells (FoxP3+CD4+cells × 100 divided by the number of CD4+ cells) (F). The number of animals evaluated was n = 19 (Sham) and n = 17 (STZ). Differences between the indicated cohorts are indicated as tendency, aP = 0.053. STZ: Streptozotocin-treated.



was not significant[25].We observed major differences between hypergly

cemic and normoglycemic mice when analyzing immune cells in the blood and the spleen in MRL/MpJ mice. We noticed (1) increased percentage of regulatory Tcells and (2) decreased percentage of FoxP3 Tcells in the spleen, as well as an (3) increased number of leukocytes in the blood of STZtreated mice (Figures 4AC and 5EG). These findings suggest that hyperglycemia might rather influence the overall immune system and only indirectly affect AIP itself. This interpretation is consistent with preclinical studies, which analyzed the influence of hyperglycemia on regulatory Tcells in mice not suffering from AIP. In these animals, hyperglycemia also increased the number of CD4+CD25+Foxp3+ regulatory Tcells in lymph nodes and the spleen of mice[26,27].

For treating AIP in the clinic, guidelines recommend to adjust blood glucose concentration before starting a steroid therapy[28,29]. This is mainly based on publications suggesting that a preexisting DM before the onset of AIP is worsening in 75% of patients after the start of a steroid therapy[28,29]. However, our preclinical study shows that hyperglycemia does not have a negative influence on AIP. Critical attitudes towards adjusting the blood glucose concentration in patients suffering from AIP have been previously published. For example, in one third of all cases, DM even worsened after insulin therapy[15]. Moreover, it was reported that treatment of diabetes with insulin led to hypoglycemic attacks in 10 from 50 AIP patients[13]. In addition, several clinical studies could demonstrate that DM improved in many cases immediately after steroid therapy[15,30]. These clinical studies argue against a tight control of blood glucose in AIP patients. Although our study has the limitation to be only a preclinical study on mice, it also suggests that an aggressive adjustment of blood glucose concentration might not be necessary as a prerequisite for the treatment of AIP. For final clarification of this issue, a clinical study evaluating if a tight adjustment of blood glucose in addition to steroid therapy is beneficial or harmful to patients

with AIP might need to be pursued.

ARTICLE HIGHLIGHTSResearch background In about 42%-66% of patients with autoimmune pancreatitis, hyperglycemia can be observed. Thus, hyperglycemia is a frequent and important complication of this disease. However, it is not known if it merely reflects the severity of pancreatitis or whether it can also influence the progression of autoimmune pancreatitis.

Research motivationFor treating autoimmune pancreatitis in the clinic, guidelines recommend to adjust blood glucose concentration before starting a steroid therapy. However, critical attitudes towards adjusting the blood glucose concentration in these patients have also been published. For example, in one third of all cases, hyperglycemia even worsened after insulin therapy, and treatment of diabetes with insulin sometimes leads to hypoglycemic attacks in patients. In order to decide how important a tight adjustment of blood glucose concentration in patients with autoimmune pancreatitis is, we need to know if hyperglycemia has a positive or negative influence on the progression of this disease.

Research objectivesThe purpose of this present study was to address the question of whether diabetes can influence the progression of autoimmune pancreatitis and to analyze which aspects of this disease are affected by hyperglycemia.

Research methodsWe chose to use MRL/MpJ mice, an animal model widely used to study autoimmune pancreatitis. These mice spontaneously develop autoimmune pancreatitis. We induced hyperglycemia by repetitive intraperitoneal (ip) injection of streptozotocin in female mice and compared the extent of inflammation in the pancreas of hyperglycemic and normoglycemic animals. We also analyzed the number of immune cells in the blood. In addition, we determined the percentage of T-cells, especially regulatory T-cells in the spleen.

Research resultsSurprisingly, experimental hyperglycemia did not cause an aggravation of autoimmune pancreatitis, but moderately improved autoimmune pancreatitis. We noticed an increased percentage of regulatory T-cells in the spleen, as well as an increased number of leukocytes in the blood of hyperglycemic mice. These findings suggest that hyperglycemia might rather influence the overall immune system and only indirectly affect autoimmune pancreatitis itself.

A

Sham STZ

Leuk

ocyt

es (

× 1

09 /L)

6

5

4

3

2

1

0

a

B

Lym

phoc

ytes

(×

109 /L

)

Sham STZ

3.0

2.5

2.0

1.5

1.0

0.5

0.0

b

C

Gra

nulo

cyte

s an

d m

onoc

ytes

(×

109 /L

)

Sham STZ

5

4

3

2

1

0

c

Figure 4 Diabetes increased the number of leukocytes in the blood. Treatment with STZ raised the number of leukocytes (A); lymphocytes (B); as well as granulocytes and monocytes (C). The number of animals evaluated was n = 19 (Sham) and n = 14 (STZ). Differences between the indicated cohorts are indicated as significant, (A) aP < 0.001; (B) bP = 0.016; (C) cP = 0.001. STZ: Streptozotocin-treated.

ARTICLE HIGHLIGHTS



Research conclusionsOur preclinical study on mice supports the idea that an aggressive adjustment of blood glucose concentration might not be necessary as a prerequisite for the treatment of patients with autoimmune pancreatitis.

Research perspectivesA clinical study that evaluates whether a tight adjustment of blood glucose is

beneficial or harmful to patients should be pursued.

ACKNOWLEDGMENTSWe thank Berit Blendow, Dorothea Frenz, Maren Nerowski and Eva LorbeerRehfeldt, (Institute for Experimental Surgery, Rostock University Medical Center)

104

103

102

101

100

FL2-

FoxP

CD4+-lymphocytes

100 101 102 103 104

FL3-CD25

CD4+

CD25+

FocP3+

104

103

102

101

100

FL2-

FoxP

CD4+-lymphocytes

100 101 102 103 104

FL1-CD4

CD4+

FoxP3+

CD4+

FoxP3-

B

Sham STZ

%CD

3+ ly

mph

ocyt

es

50

40

30

20

10

0

a

C

Sham STZ

%CD

8+ T

-lym

phoc

ytes

50

40

30

20

10

0

D

Sham STZ

%CD

4+ ly

mph

ocyt

es

80

70

60

50

40

E

Sham STZ

%Fo

xp3+

T-h

elpe

r ce

lls

60

50

40

30

20

b

F

Sham STZ

%Fo

xP3+

CD

25+ T

-hel

per

cells

50

40

30

20

10

0

c

G

Sham STZ

%Fo

xp3- T

-hel

per

cells

80

70

60

50

40

30

d

Figure 5 Evaluation of leukocytes in the spleen during autoimmune pancreatitis. Representative images of stained T-helper cells and their distinction between regulatory T-cells (FoxP3+CD4+ cells), CD25 expressing regulatory T-cells (CD4+CD25+ FoxP3+ cells) and FoxP3- T-cells (FoxP3- CD4+ cells) (A); application of STZ decreased the percentage of T-lymphocytes (defined as number of CD3+ cells × 100 divided by the number of lymphocytes) (B); little differences are observed in the percentage of cytotoxic T-cells (CD8+CD3+ cells × 100 divided by the number of CD3+cells) (C); and T-helper cells (CD4+CD3+ cells × 100 divided by the number of CD3+cells) (D); STZ increased the percentage of regulatory T-cells (FoxP3+CD4+cells × 100 divided by the number of CD4+ cells) (E); and CD25 expressing regulatory T-cells (FoxP3+ CD25+ CD4+ cells × 100 divided by the number of CD4+cells) (F); the percentage of FoxP3- T-cells (FoxP3-CD4+cells × 100 divided by the number of CD4+ cells) was decreased (G). The number of animals evaluated was n = 19 (sham) and n = 17 (STZ). Differences between the indicated cohorts are indicated as tendency, (B) aP = 0.057 or as significant, (E) bP = 0.018; (F) cP = 0.021; (G) dP = 0.034. STZ: Streptozotocin-treated.

104

103

102

101

100

FL3-

CD25

Lymphocytes

100 101 102 103 104

FL1-CD4

CD4+

A



for excellent technical assistance.

REFERENCES1 SARLES H, Sarles JC, Muratore R, Guien C. Chronic inflammatory

sclerosis of the pancreas--an autonomous pancreatic disease? Am J Dig Dis 1961; 6: 688-698 [PMID: 13746542 DOI: 10.1007/BF02232341]

2 Kamisawa T, Chari ST, Giday SA, Kim MH, Chung JB, Lee KT, Werner J, Bergmann F, Lerch MM, Mayerle J, Pickartz T, Lohr M, Schneider A, Frulloni L, Webster GJ, Reddy DN, Liao WC, Wang HP, Okazaki K, Shimosegawa T, Kloeppel G, Go VL. Clinical profile of autoimmune pancreatitis and its histological subtypes: an international multicenter survey. Pancreas 2011; 40: 809-814 [PMID: 21747310 DOI: 10.1097/MPA.0b013e3182258a15]

3 Shimosegawa T, Chari ST, Frulloni L, Kamisawa T, Kawa S, Mino-Kenudson M, Kim MH, Klöppel G, Lerch MM, Löhr M, Notohara K, Okazaki K, Schneider A, Zhang L; International Association of Pancreatology. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas 2011; 40: 352-358 [PMID: 21412117 DOI: 10.1097/MPA.0b013e3182142fd2]

4 Omiyale AO. Autoimmune pancreatitis. Gland Surg 2016; 5: 318-326 [PMID: 27294040 DOI: 10.21037/gs.2015.11.02]

5 Kleeff J, Welsch T, Esposito I, Löhr M, Singer R, Büchler MW, Friess H. Autoimmune pancreatitis--a surgical disease? Chirurg 2006; 77: 154-165 [PMID: 16208510 DOI: 10.1007/s00104-005-1084-0]

6 Ectors N, Maillet B, Aerts R, Geboes K, Donner A, Borchard F, Lankisch P, Stolte M, Lüttges J, Kremer B, Klöppel G. Non-alcoholic duct destructive chronic pancreatitis. Gut 1997; 41: 263-268 [PMID: 9301509 DOI: 10.1136/gut.41.2.263]

7 Miyoshi H, Uchida K, Taniguchi T, Yazumi S, Matsushita M, Takaoka M, Okazaki K. Circulating naïve and CD4+CD25high regulatory T cells in patients with autoimmune pancreatitis. Pancreas 2008; 36: 133-140 [PMID: 18376303 DOI: 10.1097/MPA.0b013e3181577553]

8 Hori S, Nomura T, Sakaguchi S. Control of regulatory T cell development by the transcription factor Foxp3. Science 2003; 299: 1057-1061 [PMID: 12522256 DOI: 10.1126/science.1079490]

9 Yagi H, Nomura T, Nakamura K, Yamazaki S, Kitawaki T, Hori S, Maeda M, Onodera M, Uchiyama T, Fujii S, Sakaguchi S. Crucial role of FOXP3 in the development and function of human CD25+CD4+ regulatory T cells. Int Immunol 2004; 16: 1643-1656 [PMID: 15466453 DOI: 10.1093/intimm/dxh165]

10 Fukumura Y, Takase M, Mitani K, Suda K, Imamhasan A, Nobukawa B, Ueda A, Abe H, Yao T. Amount of CD4+CD25+ regulatory T cells in autoimmune pancreatitis and pilonidal sinus. Pancreas 2012; 41: 910-915 [PMID: 22466163 DOI: 10.1097/MPA.0b013e31823e3c66]

11 Ito T, Nishimori I, Inoue N, Kawabe K, Gibo J, Arita Y, Okazaki K, Takayanagi R, Otsuki M. Treatment for autoimmune pancreatitis: consensus on the treatment for patients with autoimmune pancreatitis in Japan. J Gastroenterol 2007; 42 Suppl 18: 50-58 [PMID: 17520224 DOI: 10.1007/s00535-007-2051-y]

12 Kamisawa T, Egawa N, Inokuma S, Tsuruta K, Okamoto A, Kamata N, Nakamura T, Matsukawa M. Pancreatic endocrine and exocrine function and salivary gland function in autoimmune pancreatitis before and after steroid therapy. Pancreas 2003; 27: 235-238 [PMID: 14508128 DOI: 10.1097/00006676-200310000-00007]

13 Ito T, Nakamura T, Fujimori N, Niina Y, Igarashi H, Oono T, Uchida M, Kawabe K, Takayanagi R, Nishimori I, Otsuki M, Shimosegawa T. Characteristics of pancreatic diabetes in patients with autoimmune pancreatitis. J Dig Dis 2011; 12: 210-216 [PMID: 21615876 DOI: 10.1111/j.1751-2980.2011.00498.x]

14 Miyamoto Y, Kamisawa T, Tabata T, Hara S, Kuruma S, Chiba K, Inaba Y, Kuwata G, Fujiwara T, Egashira H, Koizumi K, Sekiya R, Fujiwara J, Arakawa T, Momma K, Asano T. Short and long-term outcomes of diabetes mellitus in patients with autoimmune pancreatitis after steroid therapy. Gut Liver 2012; 6: 501-504 [PMID: 23170157 DOI: 10.5009/gnl.2012.6.4.501]

15 Nishimori I, Tamakoshi A, Kawa S, Tanaka S, Takeuchi K, Kamisawa T, Saisho H, Hirano K, Okamura K, Yanagawa N, Otsuki M; Research Committee on Intractable Pancreatic Diseases, the Ministry of Health and Welfare of Japan. Influence of steroid therapy on the course of diabetes mellitus in patients with autoimmune pancreatitis: findings from a nationwide survey in Japan. Pancreas 2006; 32: 244-248 [PMID: 16628078 DOI: 10.1097/01.mpa.0000202950.02988.07]

16 Angelopoulos N, Dervenis C, Goula A, Rombopoulos G, Livadas S, Kaltsas D, Kaltzidou V, Tolis G. Endocrine pancreatic insufficiency in chronic pancreatitis. Pancreatology 2005; 5: 122-131 [PMID: 15849483 DOI: 10.1159/000085264]

17 Czakó L, Hegyi P, Rakonczay Z Jr, Wittmann T, Otsuki M. Interactions between the endocrine and exocrine pancreas and their clinical relevance. Pancreatology 2009; 9: 351-359 [PMID: 19454837 DOI: 10.1159/000181169]

18 Zechner D, Spitzner M, Bobrowski A, Knapp N, Kuhla A, Vollmar B. Diabetes aggravates acute pancreatitis and inhibits pancreas regeneration in mice. Diabetologia 2012; 55: 1526-1534 [PMID: 22327285 DOI: 10.1007/s00125-012-2479-3]

19 Zechner D, Knapp N, Bobrowski A, Radecke T, Genz B, Vollmar B. Diabetes increases pancreatic fibrosis during chronic inflammation. Exp Biol Med (Maywood) 2014; 239: 670-676 [PMID: 24719378 DOI: 10.1177/1535370214527890]

20 Kanno H, Nose M, Itoh J, Taniguchi Y, Kyogoku M. Spontaneous development of pancreatitis in the MRL/Mp strain of mice in autoimmune mechanism. Clin Exp Immunol 1992; 89: 68-73 [PMID: 1352748 DOI: 10.1111/j.1365-2249.1992.tb06879.x]

21 Fitzner B, Holzhueter SA, Ibrahim S, Nizze H, Jaster R. Interferon-gamma treatment accelerates and aggravates autoimmune pancreatitis in the MRL/Mp-mouse. Pancreatology 2009; 9: 233-239 [PMID: 19407476 DOI: 10.1159/000199434]

22 Frossard JL, Pastor CM. Experimental acute pancreatitis: new insights into the pathophysiology. Front Biosci 2002; 7: d275-d287 [PMID: 11779694]

23 Sah RP, Dudeja V, Dawra RK, Saluja AK. Cerulein-induced chronic pancreatitis does not require intra-acinar activation of trypsinogen in mice. Gastroenterology 2013; 144: 1076-1085.e2 [PMID: 23354015 DOI: 10.1053/j.gastro.2013.01.041]

24 Schwaiger T, van den Brandt C, Fitzner B, Zaatreh S, Kraatz F, Dummer A, Nizze H, Evert M, Bröker BM, Brunner-Weinzierl MC, Wartmann T, Salem T, Lerch MM, Jaster R, Mayerle J. Autoimmune pancreatitis in MRL/Mp mice is a T cell-mediated disease responsive to cyclosporine A and rapamycin treatment. Gut 2014; 63: 494-505 [PMID: 23564336 DOI: 10.1136/gutjnl-2012-303635]

25 Ehlers L, Rohde S, Ibrahim S, Jaster R. Adoptive transfer of CD3+ T cells and CD4+ CD44 high memory T cells induces autoimmune pancreatitis in MRL/MpJ mice. J Cell Mol Med 2018; 22: 2404-2412 [PMID: 29383850 DOI: 10.1111/jcmm.13537]

26 Kaminitz A, Mizrahi K, Askenasy N. Surge in regulatory T cells does not prevent onset of hyperglycemia in NOD mice: immune profiles do not correlate with disease severity. Autoimmunity 2014; 47: 105-112 [PMID: 24328490 DOI: 10.3109/08916934.2013.866103]

27 Zhen Y, Sun L, Liu H, Duan K, Zeng C, Zhang L, Jin D, Peng J, Ding W, Zhao Y. Alterations of peripheral CD4+CD25+Foxp3+ T regulatory cells in mice with STZ-induced diabetes. Cell Mol Immunol 2012; 9: 75-85 [PMID: 21983870 DOI: 10.1038/cmi.2011.37]

28 Kamisawa T, Okazaki K, Kawa S, Ito T, Inui K, Irie H, Nishino T, Notohara K, Nishimori I, Tanaka S, Nishiyama T, Suda K, Shiratori K, Tanaka M, Shimosegawa T; Working Committee of the Japan Pancreas Society and the Research Committee for Intractable Pancreatic Disease supported by the Ministry of Health, Labour and Welfare of Japan. Amendment of the Japanese Consensus Guidelines for Autoimmune Pancreatitis, 2013 III. Treatment and prognosis of autoimmune pancreatitis. J Gastroenterol 2014; 49: 961-970 [PMID: 24639058 DOI: 10.1007/s00535-014-0945-z]

29 Kamisawa T, Shimosegawa T, Okazaki K, Nishino T, Watanabe H, Kanno A, Okumura F, Nishikawa T, Kobayashi K, Ichiya T, Takatori



H, Yamakita K, Kubota K, Hamano H, Okamura K, Hirano K, Ito T, Ko SB, Omata M. Standard steroid treatment for autoimmune pancreatitis. Gut 2009; 58: 1504-1507 [PMID: 19398440 DOI: 10.1136/gut.2008.172908]

30 Farris AB 3rd, Lauwers GY, Deshpande V. Autoimmune pancreatitis-related diabetes: quantitative analysis of endocrine islet cells and inflammatory infiltrate. Virchows Arch 2010; 457: 329-336 [PMID: 20632032 DOI: 10.1007/s00428-010-0948-y]

P- Reviewer: Friedel D, Vagholkar KR, Zhao JB S- Editor: Wang XJ L- Editor: Filipodia E- Editor: Yin SY


© 2018 Baishideng Publishing Group Inc. All rights reserved.

Published by Baishideng Publishing Group Inc7901 Stoneridge Drive, Suite 501, Pleasanton, CA 94588, USA

Telephone: +1-925-223-8242Fax: +1-925-223-8243

E-mail: [email protected] Desk: http://www.f6publishing.com/helpdesk

http://www.wjgnet.com

I S S N 1 0 0 7 - 9 3 2 7

9 7 7 1 0 07 9 3 2 0 45

2 8

Documents

ISSN 1007-9327 (print) ISSN 2219-2840 (online) World ... · 3145 Integrated genomic analysis for prediction of survival for patients with liver cancer using The Cancer Genome Atlas